Intended for healthcare professionals

Views And Reviews Acute Perspective

David Oliver: Private practice by NHS doctors—still controversial?

BMJ 2018; 362 doi: https://doi.org/10.1136/bmj.k3480 (Published 14 August 2018) Cite this as: BMJ 2018;362:k3480
  1. David Oliver, consultant in geriatrics and acute general medicine
  1. Berkshire
  1. davidoliver372{at}googlemail.com

The issue of NHS doctors practising privately still sparks heated debate among the profession, press, and public. The ongoing renegotiation of the consultant contract,1 the contested lifting of the pay freeze on NHS staff,234 and the finding that pay has fallen dramatically in real terms for doctors and other NHS staff since 2010,5 have thrown this into sharper relief. Why wouldn’t they want to maximise their earnings potential and better support their families?

And some on the political right argue that, taking into account pensions and automatic increments, public sector workers have done better than the private sector and that UK doctors are high earners by international comparison.6789 The potential in England for swathes of NHS provision to be opened up to private providers after the 2012 Health and Social Care Act leads us to consider where their clinicians might come from.10

In 2015 the cardiologist John Dean wrote a piece for The BMJ entitled “Private practice is unethical and doctors should give it up.”11 The article was part j’accuse and part confessional, as he admitted to having done plenty of private work before seeing the light.

Many readers responded, including NHS doctors with a private practice who defended it resolutely. The response that struck me the most was from an obstetrician, Malcolm Dickson.12 He argued that the consultants most engaged in private practice tended to give a better service to their NHS patients, as this would generate more custom.

In many other health systems a fee for service model is commonplace and uncontentious, and doctors in some specialties can make multiples of typical public sector professional earnings. But NHS specialist doctors are employed by their hospital on national public salary scales. The contract and job planning process currently allows for some time spent each week working at local private providers and supplementing NHS pay.

Dean’s main arguments were that profit and personal financial gain did not mix with caring for sick, scared, or worried patients and could lead to conflicts of interest in clinicians who should base decisions solely on need, not personal gain. Also, that private medicine is a bit of a confidence trick: patients often think that they’re buying something better—a nice physical environment, better privacy, hotel facilities. In reality, he argued, they were mostly just jumping queues, with private practice existing on the back of limited access and waiting times in the NHS.

Private providers cherry pick lines of activity and patient groups they can monetise, which can scupper their local NHS trust’s business model

I’m being careful not to express a personal view, although I’ve never practised privately and don’t wish to. But I can think of more arguments in support of Dean. The incentive for NHS specialist doctors to help improve waiting times and access is surely reduced if their private practice exists symbiotically with their NHS work. Local private units also often compete with the NHS for staff and business, even if some private providers have helped reduce NHS waiting times as public contractors.

By their nature, private providers cherry pick lines of activity and patient groups that they can monetise, which can then scupper their local NHS trust’s business model.

Private practice by NHS doctors can further entrench inequalities in pay and staffing across specialties, genders, and regions.13 Only a handful of specialties allow major potential for significant private practice earnings, and more affluent catchment areas offer far greater potential for private work. And the private sector doesn’t bear the publicly funded cost of training, registering, regulating, or revalidating most of the clinical staff it employs.

Still, we already have major gaps in the medical workforce,14 and anything that helps morale or earning power could help retain doctors. Highly trained NHS doctors have transferable and hard won skills that they could take out of the country or, in some cases, completely to the private sector. Shouldn’t they be allowed to make the going rate, especially if it keeps them offering services to NHS patients for most of each week?

Doctors often report greater professional satisfaction when practising in a private unit where they can give patients adequate time and better access to treatment. They would argue that their commitment is as much to medicine and good patient care as to an institution.

Is private practice by NHS doctors still controversial? I’d be keen to hear readers’ thoughts, so please post your rapid responses.

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